Provider Demographics
NPI:1851588669
Name:TREACY, KATHLEEN (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:TREACY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-2419
Mailing Address - Country:US
Mailing Address - Phone:203-621-3700
Mailing Address - Fax:203-332-0376
Practice Address - Street 1:731 MAIN ST STE 122
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2872
Practice Address - Country:US
Practice Address - Phone:203-261-7090
Practice Address - Fax:888-856-3413
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060333104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004234877Medicaid